Research

JAMA | Preliminary Communication

Treatment of 5 Critically Ill Patients With COVID-19 With Convalescent Plasma

Chenguang Shen, PhD; Zhaoqin Wang, PhD; Fang Zhao, PhD; Yang Yang, MD; Jinxiu Li, MD; Jing Yuan, MD; Fuxiang Wang, MD;
Delin Li, PhD; Minghui Yang, PhD; Li Xing, MM; Jinli Wei, MM; Haixia Xiao, PhD; Yan Yang, MM; Jiuxin Qu, MD; Ling Qing, MM;
Li Chen, MD; Zhixiang Xu, MM; Ling Peng, MM; Yanjie Li, MM; Haixia Zheng, MM; Feng Chen, MM; Kun Huang, MM; Yujing
Jiang, MM; Dongjing Liu, MD; Zheng Zhang, MD; Yingxia Liu, MD; Lei Liu, MD

Editorial
IMPORTANCE Coronavirus disease 2019 (COVID-19) is a pandemic with no specific Audio and Video and
therapeutic agents and substantial mortality. It is critical to find new treatments. Supplemental content

OBJECTIVE To determine whether convalescent plasma transfusion may be beneficial in the

treatment of critically ill patients with severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) infection.

DESIGN, SETTING, AND PARTICIPANTS Case series of 5 critically ill patients with
laboratory-confirmed COVID-19 and acute respiratory distress syndrome (ARDS) who met the
following criteria: severe pneumonia with rapid progression and continuously high viral load
despite antiviral treatment; PAO2/FIO2 <300; and mechanical ventilation. All 5 were treated
with convalescent plasma transfusion. The study was conducted at the infectious disease
department, Shenzhen Third People's Hospital in Shenzhen, China, from January 20, 2020,
to March 25, 2020; final date of follow-up was March 25, 2020. Clinical outcomes were
compared before and after convalescent plasma transfusion.

EXPOSURES Patients received transfusion with convalescent plasma with a SARS-CoV-2–

specific antibody (IgG) binding titer greater than 1:1000 (end point dilution titer, by
enzyme-linked immunosorbent assay [ELISA]) and a neutralization titer greater than 40 (end
point dilution titer) that had been obtained from 5 patients who recovered from COVID-19.
Convalescent plasma was administered between 10 and 22 days after admission.

MAIN OUTCOMES AND MEASURES Changes of body temperature, Sequential Organ Failure
Assessment (SOFA) score (range 0-24, with higher scores indicating more severe illness),
PAO2/FIO2, viral load, serum antibody titer, routine blood biochemical index, ARDS, and
ventilatory and extracorporeal membrane oxygenation (ECMO) supports before and after
convalescent plasma transfusion.

RESULTS All 5 patients (age range, 36-65 years; 2 women) were receiving mechanical
ventilation at the time of treatment and all had received antiviral agents and
methylprednisolone. Following plasma transfusion, body temperature normalized within 3
days in 4 of 5 patients, the SOFA score decreased, and PAO2/FIO2 increased within 12 days
(range, 172-276 before and 284-366 after). Viral loads also decreased and became negative
within 12 days after the transfusion, and SARS-CoV-2–specific ELISA and neutralizing antibody
titers increased following the transfusion (range, 40-60 before and 80-320 on day 7). ARDS
resolved in 4 patients at 12 days after transfusion, and 3 patients were weaned from
mechanical ventilation within 2 weeks of treatment. Of the 5 patients, 3 have been
discharged from the hospital (length of stay: 53, 51, and 55 days), and 2 are in stable condition
at 37 days after transfusion.

CONCLUSIONS AND RELEVANCE In this preliminary uncontrolled case series of 5 critically ill
patients with COVID-19 and ARDS, administration of convalescent plasma containing Author Affiliations: Author
neutralizing antibody was followed by improvement in their clinical status. The limited sample affiliations are listed at the end of this
size and study design preclude a definitive statement about the potential effectiveness of this article.

treatment, and these observations require evaluation in clinical trials. Corresponding Authors: Yingxia
Liu, MD (yingxialiu@hotmail.com),
Zheng Zhang, MD (zhangzheng1975
@aliyun.com), and Lei Liu, MD
(liulei3322@aliyun.com), Shenzhen
Third People’s Hospital, Second
Hospital Affiliated to Southern
University of Science and Technology,
JAMA. doi:10.1001/jama.2020.4783 No. 29, Bulan Road, Longgang
Published online March 27, 2020. District, Shenzhen 518112, China.

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 Research Preliminary Communication
T
he epidemic of severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) originating in Wuhan,
China, has rapidly spread worldwide.1 As of March 24,
2020, China had reported 81 767 cases with 3281 deaths, and
the World Health Organization declared coronavirus disease
2019 (COVID-19) a pandemic. As of March 18, 2020, cases
were reported in approximately 195 countries.2
No specific therapeutic agents or vaccines for COVID-19 are
available.3 Several therapies, such as remdesivir and favipira-
vir, are under investigation,3,4 but the antiviral efficacy of these
drugs is not yet known. The use of convalescent plasma was
recommended as an empirical treatment during outbreaks of
Ebola virus in 2014, and a protocol for treatment of Middle East
respiratory syndrome coronavirus with convalescent plasma
was established in 2015.5 This approach with other viral infec-
tions such as SARS-CoV, H5N1 avian influenza, and H1N1 in-
fluenza also suggested that transfusion of convalescent plasma
was effective.6-10 In previous reports, most of the patients re-
ceived the convalescent plasma by single transfusion.9-11 In a
study involving patients with pandemic influenza A(H1N1) 2009
virus infection, treatment of severe infection with convales-
cent plasma (n = 20 patients) was associated with reduced re-
spiratory tract viral load, serum cytokine response, and
mortality.10 In another study involving 80 patients with SARS,
administration of convalescent plasma was associated with a
higher rate of hospital bxdischarge at day 22 from symptom on-
set compared with patients who did not receive convalescent
plasma.12 Accordingly, these findings raise the hypothesis that
use of convalescent plasma transfusion could be beneficial in
patients infected with SARS-CoV-2.
The purpose of this study was to describe the initial clini-
cal experience with convalescent plasma transfusion admin-
istered to critically ill patients with COVID-19.
Methods
This study was conducted at the infectious disease depart-
ment, Shenzhen Third People's Hospital, Shenzhen, China,
from January 20, 2020, to March 25, 2020, and the final date
of follow-up was March 25, 2020. The study was approved by
the ethics committees from Shenzhen Third People’s Hospi-
tal, and each patient gave written informed consent.
Patients
Patients with laboratory confirmed COVID-19, diagnosed
using quantitative reverse transcriptase–polymerase chain
reaction (qRT-PCR) (GeneoDX Co, Ltd) 13 were eligible to
receive convalescent plasma treatment if they fulfilled the
following criteria: (1) had severe pneumonia with rapid pro-
gression and continuously high viral load despite antiviral
treatment; (2) PAO2/FIO2 of <300 (PAO2 measured in mm Hg and
FIO2 measured as fraction of inspired oxygen)14; and (3) were
currently or had been supported with mechanical ventilation.
The serum of each recipient was obtained and enzyme-linked
immunosorbent assay (ELISA) and neutralizing antibody titers
were tested one day prior to the convalescent plasma transfu-
sion. The ABO blood types of the patients were determined for
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Treatment of Critically Ill Patients With COVID-19 With Convalescent Plasma
Key Points
Question Could administration of convalescent plasma
transfusion be beneficial in the treatment of critically ill patients
with coronavirus disease 2019 (COVID-19)?
Findings In this uncontrolled case series of 5 critically ill patients
with COVID-19 and acute respiratory distress syndrome (ARDS),
administration of convalescent plasma containing neutralizing
antibody was followed by an improvement in clinical status.
Meaning These preliminary findings raise the possibility that
convalescent plasma transfusion may be helpful in the treatment
of critically ill patients with COVID-19 and ARDS, but this approach
requires evaluation in randomized clinical trials.
potential compatibility with the convalescent plasma donor, and
each received 2 consecutive transfusions of 200 to 250 mL of
ABO-compatible convalescent plasma (400 mL of convales-
cent plasma in total) on the same day it was obtained from the
donor. The patients received antiviral agents continuously un-
til the SARS-CoV-2 viral loads became negative.
Disease Severity Classification
Patients with laboratory-confirmed COVID-19 infection who
had any of the following were considered in critical condi-
tion: (1) respiratory failure requiring mechanical ventilation,
(2) shock, identified by the use of vasopressor therapy and el-
evated lactate levels (>2 mmol/L) despite adequate fluid re-
suscitation, or (3) failure of other organs requiring admission
to the intensive care unit (ICU).
Donors
The 5 donors of convalescent plasma were between the ages
of 18 and 60 years. The donors had recovered from SARS-
CoV-2 infection and were invited to donate their convales-
cent plasma after written informed consent was obtained. All
donors had been previously diagnosed with laboratory-
confirmed COVID-19 and subsequently tested negative for
SARS-CoV-2 and other respiratory viruses, as well as for
hepatitis B virus, hepatitis C virus, HIV, and syphilis at the
time of blood donation. The donors had been well (asymp-
tomatic) for at least 10 days, with a serum SARS-CoV-2–
specific ELISA antibody titer higher than 1:1000 and a neu-
tralizing antibody titer greater than 40. Following donation,
400 mL of convalescent plasma was obtained from each
donor by apheresis, and the plasma was immediately trans-
fused to the recipients on the same day it was obtained.
Clinical Information
Clinical information for the 5 patients before and after conva-
lescent plasma transfusion was obtained from a review of the
hospital computer medical system and included the follow-
ing: demographic data, days of admission from symptom on-
set, and presenting symptoms; data about various treat-
ments, including mechanical ventilation, antiviral therapies,
and steroids; clinical data, including body temperature,
PAO2/FIO2, and Sequential Organ Failure Assessment (SOFA)
score (range 0-24, with higher scores indicating more severe
jama.com
 Treatment of Critically Ill Patients With COVID-19 With Convalescent Plasma Preliminary Communication Research

illness); laboratory data, including white blood cell count, lym-
phocyte count, chemistry panels assessing liver and kidney
function, cycle threshold value (Ct), inflammatory factors
C-reactive protein (CRP), procalcitonin, and IL-6, and serum
antibody titer (IgG, IgM, and neutralizing antibodies); data from
chest imaging studies; and information on complications, such
as acute respiratory distress syndrome (ARDS), bacterial pneu-
monia, and multiple organ dysfunction syndrome.
Quantitative RT-PCR
The qRT-PCR for SARS-CoV-2 was assessed as described
previously.13 Nasopharyngeal specimens collected during hos-
pitalization were sent to the laboratory in a viral transport case.
Total nucleic acid extraction from the samples was per-
formed using the QIAamp RNA Viral Kit (Qiagen), and qRT-PCR
was performed using a commercial kit specific for 2019-nCoV
detection (GeneoDX Co) approved by the China Food and Drug
Administration. Each RT-PCR assay provided a Ct value, which
is the number of cycles required for the fluorescent signal to
cross the threshold for a positive test: a higher Ct value is cor-
related with a lower viral load. The specimens were consid-
ered positive if the Ct value was 37.0 or lower and negative if
the results were undetermined. Specimens with a Ct value
higher than 37 were repeated. The specimen was considered
positive if the repeated results were the same as the initial re-
sult and between 37 and 40. If the repeated Ct was undetect-
able, the specimen was considered negative. All procedures
involving clinical specimens and SARS-CoV-2 were per-
formed in a biosafety level 3 laboratory. The Ct values of the 5
recipients were obtained on day −1, day 1, day 3, day 7, and day
12 after the transfusion.
ELISA
Microtiter plates (Sangon Biotech) were coated overnight at 4 °C
with 4 μg/mL recombinant SARS-CoV-2 RBD (receptor bind-
ing domain) proteins (50 μL per well) expressed by our labo-
ratory through 293-T cells. The plates were washed 3 times with
phosphate-buffered saline (PBS) containing 0.1% vol/vol
Tween-20 (PBST) and blocked with blocking solution (PBS con-
taining 2% wt/vol nonfat dry milk) for 2 hours at 37 °C. The
plates were then washed with PBST. The serum samples were
diluted to 200-fold into PBS as initial concentration, and se-
rial 3-fold dilutions of serum was added to the wells and in-
cubated at 37 °C for 60 minutes. After 3 washes, 100 μL of
horseradish peroxidase–conjugated goat anti–human IgG
(for IgG antibody titer detection) and IgM (for IgM antibody titer
detection) antibodies solution (Sangon Biotech) were added
to each plate, respectively, and incubated at 37 °C for 60 min-
utes. After 5 washes, 100 μL of tetramethylbenzidine sub-
strate (Sangon Biotech) was added at room temperature in
the dark. After 15 minutes, the reaction was stopped with
a 2 M H2SO4 solution (sulfuric acid). The absorbance was mea-
sured at 450 nm. All samples were run in triplicate. The ELISA
titers were determined by end point dilution.
Serum Neutralization Assay
Vero cells (104) were seeded 24 hours before the infection in a
96-well plate (Costar). On the day of infection, the cells were

Table 1. Clinical Characteristics of SARS-CoV-2-Infected Patients Who Received Convalescent Plasma

Patient
1 2 3 4 5
Sex Male Male Female Female Male
Age, y 70s 60s 50s 30s 60s
Weight, kg 55 85 60 41.5 87
Smoking No No No No No
Blood type B B B A B
Coexisting chronic diseases None Hypertension; mitral None None None
insufficiency
Disease presentation and course
Estimated incubation period, da 1 7 3 7 15
Interval between symptom onset 2 4 2 2 3
and admission, d
Interval between admission 22 10 20 19 20
and plasma transfusion, d
Complications prior to plasma Bacterial Bacterial pneumonia; Severe ARDS Severe ARDS Severe ARDS
transfusion pneumonia; severe fungal pneumonia;
ARDS; MODS severe ARDS;
myocardial damage
Most severe disease classification Critical Critical Critical Critical Critical
Treatments
Steroids Methylprednisolone Methylprednisolone Methylprednisolone Methylprednisolone Methylprednisolone
Antivirals Lopinavir/ritonavir; Lopinavir/ritonavir; Lopinavir/ritonavir; Interferon alfa-1b; Lopinavir/ritonavir;
interferon alfa-1b; arbidol; darunavir interferon alfa-1b; favipiravir interferon alfa-1b
favipiravir
a
Abreviations: ARDS, acute respiratory distress syndrome; MODS, multiple organ Estimated incubation period defined as interval between estimated exposure
dysfunction syndrome; SARS-CoV-2, severe acute respiratory syndrome to SARS-CoV-2 and symptom onset.
coronavirus 2.

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 Research Preliminary Communication Treatment of Critically Ill Patients With COVID-19 With Convalescent Plasma

Table 2. Comparison of Viral Load, Clinical Indexes, and Laboratory Results Before and After
Convalescent Plasma Transfusion

Patient
1 2 3 4 5
Clinical characteristics
Body temperature, °C
Just before transfusion 38.6 39.0 37.6 38.3 39.0
Day 1 posttransfusion 38.5 36.8 37.7 37.9 39.0
Day 3 posttransfusion 38.1 36.6 37.0 36.6 36.8
Day 7 posttransfusion 37.8 37.2 36.5 37.9 36.8
Day 12 posttransfusion 37.0 36.8 36.6 36.8 37.9
SOFA scorea
Just before transfusion 5 10 3 3 2
Day 1 posttransfusion 4 12 4 3 2
Day 3 posttransfusion 6 10 3 2 2
Day 5 posttransfusion 5 11 2 2 2
Day 7 posttransfusion 3 7 2 2 1
Day 12 posttransfusion 2 4 2 1 1
PAO2/FIO2b
Just before transfusion 276 209 172 188 205
Day 1 posttransfusion 300 134 184 242 292
Day 3 posttransfusion 220 230 164 233 304
Day 7 posttransfusion 245 206 220 290 230
Day 12 posttransfusion 284 316 342 322 366
Ct valuec (viral load proxy)
On admission to hospital 23.0 19.7 18.9 38.0 28.0
Lowest value during hospitalizationd 19.2 19.7 18.9 26.6 26.5
(highest viral load)
Just before plasma transfusion 28.5 22.0 33.0 26.6 35.9
Day 1 posttransfusion 30.0 23.7 38.5 28.0 Negative
Day 3 posttransfusion 34.4 25.0 Negative Negative Negative
Day 7 posttransfusion 38.0 32.0 Negative Negative Negative
Day 12 posttransfusion Negative Negative Negative Negative Negative
Mechanical ventilation
Onset, days before transfusion 11 2 12 9 2
Extubated, days posttransfusion Intubated Intubated 2 9 9
ECMO
Onset, days before transfusion Not received 1 Not received Not received Not received
Removal, days posttransfusion NA 5 NA NA NA
Laboratory findings
C-reactive protein, mg/L (normal range, <8)
Before transfusion 163.4 242.8 65. 156.0 173.1
Day 1 posttransfusion 146.2 223.0 108.3 NT 186.8
Day 3 posttransfusion 115.1 75.2 78.7 160.8 233.7
Day 5 posttransfusion 31.3 10.4 74.7 NT 260.4
Day 7 posttransfusion 31.2 13.9 6.2 9.6 5.5
Day 12 posttransfusion 5.3 33.1 NT 5.8 3.2
Procalcitonin, ng/mL (normal range, <0.1)
Before transfusion 1.2 7.3 0.1 0.2 0.2
Day 1 posttransfusion 1.3 19.7 0.1 0.08 0.4
Day 3 posttransfusion 1.6 13.9 0.09 0.07 1.5
Day 5 posttransfusion 0.9 1.8 0.08 NT 0.9
Day 7 posttransfusion 1.1 0.1 0.04 0.04 0.09
Day 12 posttransfusion 0.4 0.2 NT 0.04 0.07

(continued)

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 Treatment of Critically Ill Patients With COVID-19 With Convalescent Plasma Preliminary Communication Research

Table 2. Comparison of Viral Load, Clinical Indexes, and Laboratory Results Before and After
Convalescent Plasma Transfusion (continued)

Patient
1 2 3 4 5
IL-6, pg/mL (normal range, 0-7)
Before transfusion 70.5 438.2 63.9 79.1 87.8
Day 1 posttransfusion 74.9 NT 118.5 39.3 NT
Day 3 posttransfusion 34.5 1045.0 67.0 25.8 797.9
Day 5 posttransfusion 24.1 334.1 590.5 NT NT
Day 7 posttransfusion 30.8 29.8 174.3 34.0 69.9
Day 12 posttransfusion 6.1 31.8 NT 2.7 54.9
Length of hospital stay, d Remains Remains 53 51 55
hospitalized hospitalized
Current status as of March 25, 2020 Stable, still Stable, still Discharged Discharged Discharged
receiving receiving home home home
mechanical mechanical
ventilation ventilation

Abbreviations: Ct, cycle threshold; ECMO, extracorporeal membrane oxygenation; NT, not tested.
a
The SOFA score is calculated using 6 systems: respiratory, coagulation, hepatic, cardiovascular, central nervous system,
and kidney. A score of 0 is given for normal function through to 4 for most abnormal for each system. The worst values
on each day are recorded, and the final SOFA score is the sum of the scores of each system.
b
PAO2/FIO2 ratio was defined as the ratio of the partial pressure of arterial oxygen to the percentage of inspired oxygen.
c
Cycle threshold is the number of polymerase chain reaction cycles required for gene amplification. A higher Ct value is
correlated with a lower viral load.
d
Lowest value (highest viral load) between hospital admission and plasma transfusion.

washed twice. Serum samples from patients were incubated
at 56 °C for 30 minutes and then diluted 2-fold in cell culture
medium (modified eagle medium). Aliquots (40 μL) of di-
luted serum samples (from 2-fold to 2056-fold) were added to
50 μL of cell culture medium containing 50 times the tissue
culture infective dose (TCID50) of the BetaCoV/Shenzhen/
SZTH-003/2020 strain virus (isolated from this hospital, GI-
SAID access number: EPI_ISL_406594)15 on a 96-well plate and
incubated at 37 °C for 2 hours in CO2 5% vol/vol. Virus anti-
body mix was then added to cells in 96-well plates and plates
were incubated at 37 °C with microscopic examination for cy-
topathic effect after a 5-day incubation. The highest dilution
of serum that showed inhibition activity of SARS-CoV-2 was
recorded as the neutralizing antibody titer. Assays were per-
formed in triplicate with negative control samples from healthy
volunteers.
Results
Five patients (age range, 36-73 years; 2 women) were treated
with convalescent serum. None were smokers, and 4 of 5 had
no preexisting medical conditions. All 5 had received various
antiviral agents and steroids (Table 1). Convalescent plasma was
administered between 10 and 22 days after admission.
The Ct value at the time of admission ranged from 18.9 to
38.0, and on the day of plasma transfusion from 22.0 to 35.9
(Table 2 and Figure 1A). It increased (improved) within 1 day
after transfusion. The Ct value of patient 5 became negative
on posttransfusion day 1, patient 3 and patient 4 became nega-
tive on day 3, and patient 1 and patient 2 became negative on
day 12 after the transfusion (Table 2).
The SOFA score ranged from 2 to 10 prior to plasma trans-
fusion, and decreased to a range of 1 to 4 at 12 days following
transfusion (Table 2 and Figure 1B). The PAO2/FIO2 ranged from
172 to 276 prior to transfusion, and increased (improved) for
4 of 5 patients within 7 days after transfusion (overall range,
206-290), and increased substantially (range, 284-366) on the
12th day after the plasma treatment (Table 2 and Figure 1C).
Body temperature ranged from 37.6 to 39.0 °C before plasma
transfusion and declined to the normal range on the third day
after the transfusion (Table 2 and Figure 1D).
After the treatment, the values of the inflammatory bio-
markers CRP, procalcitonin, and IL-6 of patients 1, 2, 4, and 5
decreased; the values of CRP and procalcitonin of patient 3 de-
creased (Table 2).
The computed tomography scans of the lungs of these pa-
tients all demonstrated severe pneumonia prior to plasma
transfusion and showed improvement of the pulmonary le-
sion of patient 1 on the third day after the plasma transfusion
(eFigure 1 in the Supplement) and gradual resolution of pul-
monary lesions of other patients at 3 days after the plasma treat-
ment (eFigures 2, 3, 4, and 5 in the Supplement).
One day prior to convalescent plasma administration, the
RBD-specific IgG and IgM ELISA titers of the donors ranged be-
tween 1800 and 16 200 (ELISA end point dilution titers)
(Table 3). The neutralization titers against SARS-CoV-2 ranged
between 80 and 480 (neutralizing end point dilution titers).
The RBD-specific IgG ELISA titers of 5 recipients ranged be-
tween 1800 and 48 600 and the IgM titers between 5400 and
145 800 a day prior to the convalescent transfusion (eTable in
the Supplement). After the transfusion of convalescent plasma,
the titers of IgG and IgM in the sera of these patients in-
creased in a time-dependent manner. The IgG titers of the

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 Research Preliminary Communication Treatment of Critically Ill Patients With COVID-19 With Convalescent Plasma

Figure 1. Temporal Changes of Cycle Threshold Value, PAO2/FIO2, SOFA Score, and Body Temperature in Patients Receiving
Convalescent Plasma Transfusion

A Cycle threshold B SOFA score

45 15

Patients

40 1
2
3
10
4

SOFA score
35
5
Ct value

30
5

25

20 0
0 1 3 7 12 0 1 3 7 12
Days posttransfusion Days posttransfusion

C PAO2/FIO2 D Body temperature

400 40

Body temperature, °C 39
300
PAO2/FIO2

38

200
37

100 36
0 1 3 7 12 0 1 3 7 12
Days posttransfusion Days posttransfusion

A, Change in cycle threshold (Ct) value in nasopharyngeal swabs of infected (range 0-24, with higher scores indicating more severe illness; see footnote to
patients at day 0, day 3, day 7, and day 12 after the plasma transfusion. A Ct value Table 2 for more complete definition). C, Change in PAO2/FIO2 ratio of the treated
of 40 was defined as undetectable. B, Change in Sequential Organ Failure patients from day 0 to day 12 after treatment. D, Change in body temperature of
Assessment (SOFA) score of the patients with convalescent plasma treatment the 5 patients following plasma transfusion.

Table 3. Characteristics and Antibody Titer of Convalescent Plasma Donors

Donorsa
1 2 3 4 5
Blood type B B B A B
Donated plasma volume, mL 400 400 400 400 400
Interval between symptom onset and discharge, d 11 11 13 13 11
Interval between discharge and plasma donation, d 11 11 13 11 12
RBD-specific IgG ELISA titerb 16 200 1800 1800 5400 16 200
RBD-specific IgM ELISA titerc 16 200 1800 5400 5400 5400
Neutralizing antibody titerd 240 80 120 240 480
c
Abbreviation: RBD, receptor binding domain. ELISA end point dilution titers (IgM antibody). The expected titer of negative
a
Donors-patients were matched by number (donor 1 gave plasma to control from a healthy person is ⱕ200.
d
patient 1, etc). Neutralization end point dilution titers. The expected titer of negative control
b
ELISA end point dilution titers (IgG antibody). The expected titer of negative from a healthy person is ⱕ10.
control from a healthy person is ⱕ200.

treated patients increased to 145 800, 5400, 5400, 145 800 and sion. These IgG and IgM titers maintained a high level at 7 days
145 800, and the IgM titers increased to 145 800, 5400, 5400, after transfusion (Figure 2A and 2B; eTable in the Supple-
437 400 and 145 800, respectively, at 3 days after transfu- ment). The neutralizing antibody titers of the 5 recipients

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 Treatment of Critically Ill Patients With COVID-19 With Convalescent Plasma Preliminary Communication Research

Figure 2. Changes of Receptor Binding Domain–Specific IgG and IgM ELISA and Neutralizing Antibody Titers Before and After
Convalescent Plasma Transfusion in Patients

Patients
1
2
A RBD-specific IgG ELISA titer B RBD-specific IgM ELISA titer C Neutralizing antibody titer 3
4
150 150 1000

IgM ELISA titer, in thousands

5
IgG ELISA titer, in thousands

Neutralizing antibody titer

100 100

100
10 10

1 1 10
0 1 3 7 0 1 3 7 0 1 3 7
Days posttransfusion Days posttransfusion Days posttransfusion

Higher titer values indicate greater protection. A, Variation of RBD-specific IgG day 3, and day 7 following transfusion. The identical line segments were
ELISA titer. B, Variation of RBD-specific IgM ELISA titer. C, Variation of adjusted slightly to avoid superimposition. RBD indicates receptor binding
neutralizing antibody titer against SARS-CoV-2 in recipients in day 0, day 1, domain.

ranged between 40 and 160 before transfusion; one day after had significantly fewer deaths (20% vs 54.8%; P = .01) and
transfusion, the titers increased to 320, 80, 80, 160, and 240; a lower median lymphocyte count on ICU admission.10
on day 7, they were 320, 160, 160, 240, and 480, respectively In this study, collection and transfusion of the plasma
(Figure 2C; eTable in the Supplement). were done as previously reported.10 In addition, plasma was
All 5 patients were receiving mechanical ventilation at obtained from the donors and transfused in the recipients
the time of transfusion, and 3 patients (patients 3, 4, and 5) on the same day, which helps preserve the natural activity of
were weaned from mechanical ventilation (Table 2). Patient 2 the plasma.
was receiving ECMO at the time of plasma treatment but did Studies have shown that viral loads are highly correlated
not require ECMO on day 5 after transfusion (Table 2). with disease severity and progression.18 Fatal outcome of hu-
Patients 3, 4, and 5 were discharged from the hospital (length man influenza A(H5N1) has been associated with high viral load
of stay: 53, 51, and 55 days, respectively). As of March 25, and hypercytokinemia.19 Apart from antiviral treatment, virus-
2020, patients 1 and 2 remained hospitalized, with lengths of specific neutralizing antibody, which could accelerate virus
stay of 37 days each. clearance and prevent entry into target cells, serves as the main
mechanism for the restriction and clearance of the viruses by
the host.20-22 In the current study, SARS-CoV-2 was still detect-
able in all 5 patents even though antiviral treatment had been
Discussion given for at least 10 days, although viral load decreased and be-
In this case series, 5 patients who were critically ill with came undetectable soon after convalescent plasma treatment.
COVID-19 were treated with convalescent plasma. As As determined by ELISA, all plasma from the donors had high
assessed by Ct, viral load declined within days of treatment virus-specific IgG and IgM ELISA titers. Moreover, the neutral-
with convalescent plasma, and the clinical conditions of izing antibody titers, vital for the restriction of viral infection
these patients improved, as indicated by body temperature of the 5 recipients, significantly increased after plasma trans-
reduction, improved P AO 2 /F IO 2 , and chest imaging. Four fusion. The results highlight the possibility that antibodies from
patients who had been receiving mechanical ventilation and convalescent plasma may have contributed to the clearance of
ECMO no longer required respiratory support by 9 days after the virus and also the improvement of symptoms. In addition
plasma transfusion. to viral neutralizing antibodies, acceleration of infected cell
Previous studies have reported the use of convalescent clearance by antibodies has also been found in an in vivo study
plasma transfusion in the treatment of various infections.6,10,16 of HIV-1 virus.23 In the current study, all patients received an-
For example, patients (n = 50) with SARS had a significantly tiviral agents, including interferon and lopinavir/ritonavir, dur-
higher discharge rate by day 22 following onset of illness (73.4% ing and following convalescent plasma treatment, which also
vs 19.0%; P<.001) and lower case-fatality rate (0% vs 23.8%; may have contributed to the viral clearance observed.
P = .049) in the convalescent plasma treatment group (n = 19
patients) when compared with steroid treatment group Limitations
(n = 21).17 In another study of 93 patients with influenza This study has several limitations. First, this was a small case
A(H1N1), patients who received convalescent plasma treat- series that included no controls. Second, it is unclear if these
ment (n = 20) compared with those in the control group (n = 73) patients would have improved without transfusion of

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 Research Preliminary Communication Treatment of Critically Ill Patients With COVID-19 With Convalescent Plasma

convalescent plasma, although the change in Ct and PAO2/

FIO2 represent encouraging findings. Third, all patients were
treated with multiple other agents (including antiviral medi-
cations), and it is not possible to determine whether the im-
provement observed could have been related to therapies other
than convalescent plasma. Fourth, plasma transfusion was ad-
ministered 10 to 22 days after admission; whether a different
timing of administration would have been associated with dif-
ferent outcomes cannot be determined. Fifth, whether this ap-
proach would reduce case-fatality rates is unknown.
Conclusions
In this preliminary uncontrolled case series of 5 critically ill pa-
tients with COVID-19 and ARDS, administration of convales-
cent plasma containing neutralizing antibody was followed by
improvement in the patients’ clinical status. The limited sample
size and study design preclude a definitive statement about
the potential effectiveness of this treatment, and these obser-
vations require evaluation in clinical trials.

ARTICLE INFORMATION
Accepted for Publication: March 20, 2020.
Published Online: March 27, 2020.
doi:10.1001/jama.2020.4783
Author Affiliations: Shenzhen Key Laboratory of
Pathogen and Immunity, National Clinical Research
Center for Infectious Disease, State Key Discipline
of Infectious Disease, Shenzhen Third People's
Hospital, Second Hospital Affiliated to Southern
University of Science and Technology, Shenzhen,
China (Shen, Z. Wang, Zhao, Y. Yang, J. Li, Yuan,
F. Wang, D. Li, M. Yang, Xing, Wei, Xiao, Y. Yang, Qu,
Qing, L. Chen, Xu, Peng, Y. Li, Zheng, F. Chen,
Huang, Jiang, D. Liu, Zhang, Y. Liu, L. Liu);
Laboratory of Protein Engineering and Vaccines,
Tianjin Institute of Industrial Biotechnology,
Chinese Academy of Sciences (CAS), Tianjin, China
(D. Li, Xiao).
Author Contributions: Dr L. Liu had full access to
all of the data in the study and takes responsibility
for the integrity of the data and the accuracy of the
data analysis. Drs Shen, Z. Wang, Zhao, and Y. Yang
contributed equally.
Concept and design: Shen, Z. Wang, Yuan, F. Wang,
D. Liu, Zhang, Y. Liu, L. Liu.
Acquisition, analysis, or interpretation of data: Shen,
Yang Yang, J. Li, Yuan, D. Li, M. Yang, Xing, Wei,
Xiao, Yan Yang, Qu, Qing, L. Chen, Xu, Peng, Y. Li,
Zheng, F. Chen, Huang, Jiang, Y. Liu, L. Liu.
Drafting of the manuscript: Shen, Zhao, Yang Yang,
J. Li, Yuan, F. Wang, M. Yang, Xing, Wei, Xiao, Yan
Yang, Qu, Qing, L. Chen, Xu, Zheng, Huang, Jiang,
D. Liu, Y. Liu, L. Liu.
Critical revision of the manuscript for important
intellectual content: Shen, Z. Wang, Yang Yang,
Yuan, D. Li, Peng, Y. Li, F. Chen, Zhang, Y. Liu, L. Liu.
Statistical analysis: Yuan.
Obtained funding: Yuan, Zhang, Y. Liu, L. Liu.
Administrative, technical, or material support: Shen,
Zhao, J. Li, Yuan, F. Wang, D. Li, M. Yang, Yan Yang,
Qu, Qing, L. Chen, Zhang.
Supervision: Z. Wang, Yuan, Zhang, Y. Liu, L. Liu.
Conflict of Interest Disclosures: None reported.
Funding/Support: This work was supported by the
National Science and Technology Major Project
(2018ZX10711001, 2017ZX10103011,
2017ZX10204401), Sanming Project of Medicine in
Shenzhen (SZSM201412003, SZSM201512005),
China Postdoctoral Science Foundation
(2019T120147, 2018M641508), Shenzhen Science
and Technology Research and Development Project
(202002073000001), National Natural Science
Foundation of China (81902058), Shenzhen Science
and Technology Research and Development Project
(202002073000002), and The Key Technology
R&D Program of Tianjin (17YFZCSY01090).
Role of the Funder/Sponsor: The funding agencies
had no role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
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